Fresofol 1% MCT/LCT

Propofol.

Each 1 mL emulsion contains 10 mg propofol.
Each 20 mL ampoule and 50 mL vial contains 200 mg and 500 mg propofol, respectively.
Excipients/Inactive Ingredients: Soya-bean oil, medium-chain triglycerides, purified egg phosphatides, glycerol, oleic acid, sodium hydroxide and water for injections.

Fresofol 1% MCT/LCT is a short-acting intravenous general anaesthetic agent.

Fresofol 1% MCT/LCT is a short-acting intravenous general anaesthetic agent for: induction and maintenance of general anaesthesia; sedation of artificially ventilated patients in the intensive care unit (ICU); sedation for diagnostic and surgical procedures, alone or in combination with local or regional anaesthesia.

Fresofol 1% MCT/LCT must only be given in hospitals or adequately equipped day therapy units by physicians trained in anaesthesia or in the care of patients in intensive care.
Circulatory and respiratory functions should be constantly monitored (e.g. ECG, pulse oxymetry) and facilities for maintenance of patient airways, artificial ventilation and other resuscitation facilities should be immediately available at all times.
For sedation during surgical and diagnostic procedures, Fresofol 1% MCT/LCT should not be administered by the same person conducting the surgical or diagnostic procedure.
The dose of Fresofol 1% MCT/LCT emulsion should be individualised based on the response of the patient and premedications used.
Supplementary analgesic agents are generally required in addition to Fresofol 1% MCT/LCT.
Posology: General Anaesthesia in adults: Induction of anaesthesia: For induction of anaesthesia Fresofol 1% MCT/LCT should be titrated (approximately 20-40 mg propofol every 10 seconds) against the response of the patient until clinical signs show the onset of anaesthesia.
Most adult patients aged less than 55 years are likely to require 1.5-2.5 mg propofol/kg body weight.
In patients over this age and in patients of ASA grades III and IV, especially those with impaired cardiac function, the requirements will generally be less and the total dose of Fresofol 1% MCT/LCT may be reduced to a minimum of 1 mg propofol/kg body weight. Lower rates of administration of Fresofol 1% MCT/LCT should be used [approximately 2 ml (20 mg propofol) every 10 seconds].
Maintenance of anaesthesia: Anaesthesia can be maintained by administering Fresofol 1% MCT/LCT either by continuous infusion or repeat bolus injections.
For maintenance of anaesthesia generally doses of 4 to 12 mg propofol/kg body weight/h should be given. A reduced maintenance dose of approximately 4 mg propofol/kg body weight/h may be sufficient during less stressful surgical procedures such as minimal invasive surgery.
In elderly patients, patients in unstable general conditions, patients with impaired cardiac function or hypovolaemic patients and patients of ASA grades III and IV, the dosage of Fresofol 1% MCT/LCT may be reduced further depending on the severity of the patient's condition and on the performed anaesthetic technique.
For maintenance of anaesthesia using repeat bolus injections dose increments of propofol 25 to 50 mg propofol (=2.5-5 ml Fresofol 1% MCT/LCT) should be given according to clinical requirements.
Rapid bolus administration (single or repeated) should not be used in the elderly as this may lead to cardiopulmonary depression.
General anaesthesia in children over 1 month of age: Fresofol 1% MCT/LCT is not advised for general anaesthesia in children younger than 1 month of age.
Induction of anaesthesia: When used to induce anaesthesia, it is recommended that Fresofol 1% MCT/LCT should be titrated slowly until the clinical signs show the onset of anaesthesia.
The dose should be adjusted for age and/or body weight. Children over 8 years of age are likely to require approximately 2.5 mg propofol/kg body weight for induction of anaesthesia. Under this age the dose requirement may be higher.
The initial dose should be 3 mg propofol/kg body weight. If necessary, additional doses in steps of 1 mg propofol/kg body weight can be administered.
Lower dosages are recommended for young patients at increased risk (ASA grades III and IV).
Administration of propofol by a Target Controlled Infusion (TCI) system is not advised for induction of general anaesthesia in children.
Maintenance of anaesthesia: For maintenance of anaesthesia using continuous infusion, doses of 9 to 15 mg propofol/kg body weight/h should be given.
Younger children, less than 3 years, may need higher dosage requirements, within the range of recommended dosages, when compared with older paediatric patients.
There is no data on maintenance of anaesthesia with repeated injections of propofol in children.
Dosage should be adjusted individually and particular attention paid to the need for adequate analgesia.
A maximum duration of use of approximately 60 minutes should not be exceeded except where there is a specific indication for longer use e.g. malignant hyperthermia where volatile agents must be avoided.
Administration of propofol by a Target Controlled Infusion (TCI) system is not advised for maintenance of general anaesthesia in children.
Sedation in adults during intensive care: When used to provide sedation for ventilated patients under intensive care conditions, it is recommended that Fresofol 1% MCT/LCT should be given by continuous infusion. The dose should be adjusted according to the depth of sedation required. Usually, satisfactory sedation is achieved with administration rates in the range of 0.3 to 4.0 mg propofol/kg body weight/h. Rates of infusion greater than 4.0 mg propofol/kg body weight/h are not recommended (see Precautions).
Propofol must not be used for sedation in intensive care of patients of 16 years of age or younger (see Contraindications).
Administration of Fresofol 1% MCT/LCT by a Target Controlled Infusion (TCI) system is not advised for sedation in the Intensive Care Unit.
Sedation for diagnostic and surgical procedures in adult patients: To provide sedation during surgical and diagnostic procedures, doses and administration rates should be adjusted according to the clinical response. Most patients will require 0.5-1 mg propofol/kg body weight over 1 to 5 minutes for onset of sedation. Maintenance of sedation may be accomplished by titrating Fresofol 1% MCT/LCT infusion to the desired level of sedation. Most patients will require 1.5-4.5 mg propofol/kg body weight/h. The infusion may be supplemented by bolus administration of 10-20 mg (1-2 ml Fresofol 1% MCT/LCT) if a rapid increase of the depth of sedation is required.
In patients older than 55 years and in patients of ASA grades III and IV lower doses of Fresofol 1% MCT/LCT may be required and the rate of administration may need to be reduced.
Propofol must not be used for sedation for diagnostic and surgical procedures in patients of 16 years of age or younger.
Method of Administration: For intravenous use.
Fresofol 1% MCT/LCT can be used for infusion undiluted or diluted with Dextrose 5% intravenous infusion solution or Sodium chloride 0.9% intravenous infusion solution only, in glass infusion bottles.
Containers should be shaken before use.
Use only homogenous preparations and undamaged containers.
Prior to use, the ampoule neck or rubber membrane should be cleaned using an alcohol spray or a swab dipped in alcohol. After use, tapped containers must be discarded.
Fresofol 1% MCT/LCT is a lipid containing emulsion without antimicrobial preservatives and may support rapid growth of microorganisms.
The emulsion must be drawn aseptically into a sterile syringe or giving set immediately after opening the ampoule or breaking the vial seal. Administration must commence without delay.
Asepsis must be maintained for both Fresofol 1% MCT/LCT and infusion equipment throughout the infusion period. Co-administration of other medicinal products or fluids added to the Fresofol 1% MCT/LCT infusion line must occur close to the cannula site using a Y-piece connector or a three-way valve.
Fresofol 1% MCT/LCT must not be mixed with other solutions for infusion or injection. But 5% w/v glucose solution, 0.9% w/v sodium chloride solution or 0.18% w/v sodium chloride and 4% w/v glucose solution may be administered via suitable appendages at the cannula site.
Fresofol 1% MCT/LCT must not be administered via a microbiological filter.
Fresofol 1% MCT/LCT and any infusion equipment containing Fresofol 1% MCT/LCT are for single administration in an individual patient. After use, remaining solution of Fresofol 1% MCT/LCT has to be discarded.
Infusion of undiluted Fresofol 1% MCT/LCT: When Fresofol 1% MCT/LCT is infused undiluted, it is recommended that equipment such as burettes, drop counter, syringe pumps or volumetric infusion pumps should always be used to control infusion rates.
As usual for fat emulsions, the infusion of Fresofol 1% MCT/LCT via one infusion system must not exceed 12 hours. After 12 hours, the infusion system and reservoir of Fresofol 1% MCT/LCT must be discarded or replaced if necessary.
Infusion of diluted Fresofol 1% MCT/LCT: For administering infusion of diluted Fresofol 1% MCT/LCT, burettes, drop counters or volumetric infusion pumps should always be used to control infusion rates and to avoid the risk of accidentally uncontrolled infusion of large volumes of diluted Fresofol 1% MCT/LCT. This risk has to be taken into account when the decision for the maximum dilution in the burette is made.
The maximum dilution must not exceed 1 part of Fresofol 1% MCT/LCT with 4 parts of 5% w/v glucose solution or 0.9% w/v sodium chloride solution (minimum concentration 2 mg propofol/ml). The mixture should be prepared aseptically (controlled and validated conditions preserved) immediately prior to administration and must be administered within 6 hours after preparation.
Fresofol 1% MCT/LCT must not be mixed with other solutions for infusion or injection. However, co-administration of a 5% w/v glucose solution or 0.9% w/v sodium chloride solution or 0.18% w/v sodium chloride and 4% w/v glucose solution with Fresofol 1% MCT/LCT is permitted via a Y-piece connector close to the injection site.
To reduce pain on the injection site, lidocaine may be injected immediately before the use of Fresofol 1% MCT/LCT or Fresofol 1% MCT/LCT may be mixed, immediately for use with preservative-free lidocaine injection (20 parts of Fresofol 1% MCT/LCT with up to 1 part of 1% lidocaine injection solution) under controlled and validated aseptical conditions. The mixture has to be administered within 6 hours after preparation.
Muscle relaxants like atracurium and mivacurium should only be administered after flush of the same infusion site used for Fresofol 1% MCT/LCT.
Duration of administration: The duration of administration must not exceed 7 days.

Overdose is likely to cause cardiovascular and respiratory depression. Respiratory depression is treated with artificial ventilation. Cardiovascular depression may require lowering the patient's head and administering plasma volume substitutes and vasopressive agents.

Fresofol 1% MCT/LCT must not be used in patients with known hypersensitivity to propofol or to any of the excipients of the emulsion; in patients who are allergic to soya or peanut; for sedation in children 16 years of age and younger (see Precautions).
Use in Pregnancy & Lactation: The safety of propofol during pregnancy has not been established. Therefore, propofol should not be used in pregnant women unless clearly necessary. Propofol crosses the placenta and may be associated with neonatal depression. High doses (more than 2.5 mg propofol/kg body weight for induction or 6 mg propofol/kg bodyweight/h for maintenance of anaesthesia) should be avoided.
Studies in breast-feeding women showed that propofol is excreted in small amounts into the milk. Therefore, mothers should stop breast-feeding and discard breast milk for 24 hours after administration of propofol.

In patients with cardiac, respiratory, renal or hepatic impairment or in elderly, debilitated, hypovolaemic or epileptic patients or patients with disorders of consciousness.
Fresofol 1% MCT/LCT should be administered with caution and a reduced administration rate (see Dosage & Administration).
Cardiac, circulatory or pulmonary insufficiency and hypovolaemia should be compensated before administration of Fresofol 1% MCT/LCT.
Before anaesthesia of an epileptic patient, it should be checked that the patient has received the antiepileptic treatment. Although several studies have demonstrated efficacy in treating status epilepticus, administration of propofol in epileptic patients may also increase the risk of seizure.
Fresofol 1% MCT/LCT should not be administered in patients with advanced cardiac failure or other severe myocardial disease except with extreme caution and intensive monitoring.
The risk of relative vagotonia may be increased because propofol lacks vagolytic activity. It has been associated with reports of bradycardia (occasionally profound) and also asystole. The intravenous administration of an anticholinergic agent before induction, or during maintenance of anaesthesia should be considered, especially in situations where vagal tone is likely to predominate, or when Fresofol 1% MCT/LCT is used in conjunction with other agents likely to cause a bradycardia.
Use is not recommended with electroconvulsive therapy.
As with other sedative agents, when propofol is used for sedation during operative procedures, involuntary patient movements may occur. During procedures requiring immobility, these movements may be hazardous to the operative site.
Special care should be applied in patients with disorders of fat metabolism and in other conditions where lipid emulsions must be used with caution. If patients receive parenteral nutrition, it is necessary to take account of the amount of lipid infusion as part of the Fresofol 1% MCT/LCT formulation: 1.0 ml Fresofol 1% MCT/LCT contains 0.1 gram of fat.
Lipids should be monitored in the Intensive Care Unit treatment after 3 days.
Due to a higher dosage in patients with severe overweight, the risk of haemodynamic effects on the cardiovascular system should be taken into consideration.
Special care should be recognised in patients with a high intracranial pressure and a low mean arterial pressure as there is a risk of a significant decrease of the intracerebral perfusion pressure.
To reduce pain on the injection site during induction of anaesthesia with Fresofol 1% MCT/LCT, lidocaine can be injected prior to the propofol emulsion.
Dilutions with lidocaine solution must not be used in patients with hereditary acute porphyria.
Propofol is not advised for general anaesthesia in children younger than 1 month of age. The safety of propofol for (background) sedation in children younger than 16 years of age have not been demonstrated.
Although no causal relationship has been established, serious undesirable effects with (background) sedation in patients younger than 16 years of age (including cases with fatal outcome) have been reported during unlicensed use. In particular, these effects concerned occurrence of metabolic acidosis, hyperlipidemia, rhabdomyolysis and/or cardiac failure. These effects were most frequently seen in children with respiratory tract infections who received dosages in excess of those advised in adults for sedation in the intensive care unit. Similarly, very rare reports have been received of occurrence of metabolic acidosis, rhabdomyolysis, hyperkalaemia and/or rapidly progressive cardiac failure (in some cases with fatal outcome) in adults who were treated for more than 58 hours with dosages in excess of 5 mg propofol/kg body weight/h. This exceeds the maximum dosage of 4 mg propofol/kg body weight/h currently advised for sedation in the intensive care unit. The patients affected were mainly (but not only) seriously head-injured patients with increased intracranial pressure (ICP). The cardiac failure in such cases was usually unresponsive to inotropic supportive treatment.
Treating physicians are reminded if possible not to exceed the dosage of 4 mg propofol/kg body weight/h.
Prescribers should be alert to these possible undesirable effects and consider decreasing the propofol dosage or switching to an alternative sedative at the first sign of occurrence of symptoms. Patients with raised ICP should be given appropriate treatment to support the cerebral perfusion pressure during these treatment modifications.
Special care should be exercised when propofol is used for anaesthesia in infants and children up to 3 years of age, although currently available data do not suggest significant differences in terms of safety compared with children older than 3 years.
In isolated cases, there may be a phase of postoperative unconsciousness that may be accompanied by an increased muscle tone. The occurrence of such an event is not related to whether the patient was awake or not. Although consciousness returns spontaneously, unconscious patients should be kept under close observation.
Fresofol 1% MCT/LCT contains soybean oil, which might cause severe allergic reaction in rare cases.
Full recovery from general anaesthesia should be confirmed prior to discharge.
Effects on Ability to Drive and Use Machines: After administration of Fresofol 1% MCT/LCT, the patient should be kept under observation for an appropriate period of time. The patient should be instructed not to drive, operate machinery or work in potentially hazardous situations. The patient should not be allowed to go home unaccompanied and should be instructed to avoid consumption of alcohol.

The safety of propofol during pregnancy has not been established. Therefore, propofol should not be used in pregnant women unless clearly necessary. Propofol crosses the placenta and may be associated with neonatal depression. High doses (more than 2.5 mg propofol/kg body weight for induction or 6 mg propofol/kg body weight/h for maintenance of anaesthesia) should be avoided.
Studies in breast-feeding women showed that propofol is excreted in small amounts into the milk. Therefore, mothers should stop breast-feeding and discard breast milk for 24 hours after administration of propofol.

Commonly observed side effects of propofol are hypotension and respiratory depression. These effects depend on the propofol dose administered but also on the type of premedication and other concomitant medication. Specifically, the following side effects have been observed.
Immune system disorders: Rare (<1:1000, ≥1:10,000): Clinical features of anaphylaxis, which may include Quincke's oedema, bronchospasm, erythema and hypotension.
Psychiatric disorders: Rare (<1:1000, ≥1:10,000): Euphoria and sexual disinhibition during the recovery period.
Nervous system disorders: Common (<1:10, ≥1:100): During induction of anaesthesia spontaneous movements and myocloni, minimal excitation.
Rare <1:1,000, ≥1:10,000): Headache, vertigo, shivering and sensations of cold during the recovery period. Epileptiform movements including convulsions and opisthotonus.
Very rare (<1:10,000): Delayed epileptiform attacks, the delay period ranging from a few hours to several days. Risk of convulsions in epileptic patients after administration of propofol.
Cases of postoperative unconsciousness (see Precautions).
Cardiac disorders/Vascular disorders: Common (<1:10,1:100): During induction of anaesthesia, hypotension, bradycardia, tachycardia, hot flushes.
Uncommon (<1:100, ≥1:1000): Marked hypotension. This may require a lowering of the administration rate of Fresofol 1% MCT/LCT and/or fluid replacement therapy, if necessary, vasoconstrictive medicinal products. Account should be taken of the possibility of a severe drop in blood pressure in patients with impaired coronary or cerebral perfusion or those with hypovolaemia.
Bradycardia during general anaesthesia with progressive severity (asystole). The intravenous administration of an anticholinergic medicinal product prior to induction or during maintenance of anaesthesia should be considered (see Precautions).
Rare (<1:1,000, ≥1:10,000): Arrhythmia during the recovery period.
Thrombosis and phlebitis.
Respiratory, thoracic and mediastinal disorders: Common (<1:10, ≥1:100): During induction of anaesthesia, hyperventilation, transient apnoea, coughing, singultus.
Uncommon (<1:100, ≥1:1,000): Coughing during maintenance of anaesthesia.
rare (<1:1,000, ≥1:10,000): Coughing during the recovery period.
Very Rare (<1:10,000): Pulmonary oedema.
Gastrointestinal disorders: Rare (<1:1,000, ≥1:10,000): Nausea or vomiting during the recovery period.
Very rare (<1:10,000): Pancreatitis has been reported after administration of propofol. A causal relationship, however, could not be established.
Skin and subcutaneous tissue disorders: Very rare (<1:10,000): Severe tissue responses after accidental paravenous application.
Renal and urinary disorders: Rare (1:1,000, ≥1:10,000): Cases of discoloration of urine following prolonged administration of propofol.
General disorders and administration site conditions: Very common (>1:10): Local pain occurring during the initial injection. Prophylaxis or treatment see as follows.
The local pain which may occur during the initial injection of Fresofol 1% MCT/LCT can be minimised by the co-administration of lidocaine (see Dosage & Administration) and by injection or infusion into the larger veins of the forearm and antecubital fossa. Upon co-administration of lidocaine the following undesirable effects may occur rarely (<1:1000 to 1:10,000): Giddiness, vomiting, drowsiness, convulsions, bradycardia, cardiac arrhythmia and shock.
Rare (<1:1,000, ≥1:10,000): Cases of postoperative fever.
Very Rare (<1:10,000): There have been reports of isolated cases of severe undesirable effects presenting as a complex of symptoms including: rhabdomyolysis, metabolic acidosis, hyperkalaemia and cardiac failure, sometimes with fatal outcome. Most of these effects have been observed in patients in intensive care with doses exceeding 4 mg/kg body weight/h. (See Precautions.)

Fresofol 1% MCT/LCT can be used in combination with other medicinal products for anaesthesia (premedications, volatile anaesthetics, analgesics, muscle relaxants and local anaesthetics). Severe interactions with these medicinal products have been reported. Some of these centrally acting medicinal products may exhibit a circulatory and respiratory depressive effect, thus leading to increased effects when used together with Fresofol 1% MCT/LCT.
Lower doses may be required when general anaesthesia is carried out in conjunction with regional anaesthesia.
Concomitant use of benzodiazepines, parasympatholytic agents or inhalational anaesthetics has been reported to prolong the anaesthesia and to reduce the respiratory rate.
After additional premedication with opioids, the sedative effects of propofol may be intensified and prolonged, and there may be a higher incidence and longer duration of apnoea.
It should be taken into consideration that concomitant use of propofol and medicinal products for premedication, inhalation agents or analgesic agents may potentiate anaesthesia and cardiovascular side effects.
Concomitant use of central nervous system depressants (e.g. alcohol, general anaesthetics and narcotic analgesics) will result in intensification of their sedative effect. When Fresofol 1% MCT/LCT is combined with centrally depressant agents administered parenterally, severe respiratory and cardiovascular depression may occur.
After administration of fentanyl, the blood level of propofol may be temporarily increased with an increase in the rate of apnoea.
Bradycardia and cardiac arrests may occur after treatment with suxamethonium or neostigmin.
Leucoencephalopathy has been reported with administration of lipid emulsions such as propofol in patients receiving cyclosporine.
Incompatibilities: Fresofol 1% MCT/LCT should not be mixed prior to administration with injection or infusion solutions other than 5% w/v glucose solution or 0.9% w/v sodium chloride solution or 1% lidocaine injection solution (see Dosage & Administration). Final propofol concentration must not be below 2 mg/ml.

Pharmaceutical precautions: Fresofol 1% MCT/LCT should not be used after expiry date.
Prior to use, the ampoule neck or rubber membrane should be cleaned using an alcohol spray or a swab dipped in alcohol. After use, tapped containers must be discarded.
Administration of the emulsion must commence without delay after opening the ampoule or breaking the vial seal.
The infusion of undiluted Fresofol 1% MCT/LCT via one infusion system must not exceed 12 hours.
Dilutions with 5% w/v glucose solution or 0.9% w/v sodium chloride solution or an admixture 1% lidocaine injection solution (at least 2 mg propofol per mL) should be prepared aseptically (controlled and validated conditions preserved) immediately before administration and must be administered within 6 hours after preparation.
For single use. Any unused emulsion must be discarded.
Containers should be shaken before use.
If two layers can be seen after shaking the emulsion should not be used.
Use only homogenous preparations and undamaged containers.

Do not store above 25°C. Do not freeze.

Anaesthetics - Local & General

N01AX10 - propofol ; Belongs to the class of other general anesthetics.

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